The Latin American branch of the World Health Organization and
UNICEF both praised the
program.[1][2]
According to WHO statistics infant mortality fell from 23 to 20 in
males and 19 to 17 in females per 1000 births between 2003 and
2005. [5][6] In addition, Russian representatives have
visited Venezuelan neighborhoods in order to study Venezuelan
public clinics and Russian
officials are considering implementing a similar program in Russia.

Of a planned 8500 Barrio Adentro I centers, 2708 had been built
by May, 2007, using an investment of around US$126m, with a further
3284 under construction.[3]
As of 2006, the staff included 31,439 professionals, technical
personnel, and health technicians, of which 15,356 were Cuban
doctors and 1,234 Venezuelan doctors.[4]

Background

The Barrio Adentro program was developed against a background of
a public health sector crumbling under long-term financial
pressure. As part of the neoliberalisation programme of the early
1990s under President Rafael Caldera, a Venezuela struggling
with inflation and a low oil price (oil being its primary export)
was forced into spending cuts and privatisation in a
number of sectors, including healthcare. A 1989 decentralisation
law contributed to the trend; from 1993, state governors could
request the transfer of public healthcare in their state to their
control, and the inability to cope with the new responsibility
encouraged cuts and privatisation. Cost recovery became
increasingly prevalent through "voluntary" contributions from
users.[5]
In addition to the problems with the healthcare system, over the
course of the decade health problems caused by poverty (infectious
and deficiency diseases) increased. By 1999, 67.7% of the
Venezuelan population was living in poverty, from 44.4% in
1990.[5]

In 1999, following the election of Hugo Chavez, the Ministry of
Health planned to develop a new National Public Health System, with
a particular focus on health promotion, disease prevention,
community participation, and the strengthening of the primary
health care infrastructure. The 2000/1 annual report by PROVEA
highlighted a number of positive features of the new approach,
including a wider availability of health services through
progressive elimination of users’ fees.[5]

Origins

The Barrio Adentro program is an example of Latin American
social medicine (LASM), which became prominent in the 1960s and
70s. Amongst others in Latin America, both Salvador
Allende in Chile in the early 1970s and Tabaré
Vázquez in Uruguay from 2005 have implemented LASM
principles.[6]
LASM's roots can be traced back to 19th-century European social
medicine (particularly the work of social medicine pioneer Rudolf Virchow),
which was exported to Latin America in the early twentieth
century.[6]

LASM emphasises a collective and holistic approach to healthcare, rather than
merely treating the particular symptoms of one individual. Thus the
importance of health promotion and disease prevention—informed by
the political-economic and social determinants of health—is
stressed, over a merely reactive treatment of health problems as
they occur.[6]
LASM incorporates the concept of primary health care (as defined by
the 1978 Alma Ata Declaration), of which
the "simplified healthcare" adopted in rural Venezuela in the 1960s
and 70s was one form.[7][8] More
recently, in 2006, Barrio Adentro has been described by the
Director of the PAHO as "the culmination of 25 years of
experience in Latin America and the rest of the world in
transforming health systems through the primary health care
strategy."[4]

When Hugo Chávez became President in 1999, he sought to
implement LASM principles, beginning with their incorporation into
the new 1999
Venezuelan Constitution, in articles 83-85 of Title III. These
articles enshrine free and high quality healthcare as a human right
guaranteed to all Venezuelan citizens.[9]
Notably, Article 84 of Title III follows LASM principles in
declaring health promotion and disease prevention a priority; it
also describes the healthcare system as "decentralised and
participative" and declares that the community has "the right and
the duty" to be involved in policy decisions regarding the public
health system. In addition Article 85 mandates that the government
provide adequate funding for the public healthcare system, while
Article 84 explicitly proscribes its privatization.[9]

Initial attempts to transform the Ministry of Health to LASM
principles, in the 1999–2003 period, met with little success. The
Venezuelan Medical Federation was aligned with the Punto Fijo parties, and
many of its members in private health care opposed the new emphasis
on the public sector. At the same time that the new policies failed
to make much ground within the healthcare system, the traditional
top-down way in which the policies were developed and carried out
prevented a strong connection with the concerns of the poor.[6]

The origins of a different approach for carrying out LASM lay in
the Libertador
municipality of Caracas,[10] which
in 2003 (under a pro-Chávez mayor, Freddy Bernal) set up an
Institute for Endogenous Development (IED), broadly intended to
improve living conditions through the active participation of the
local population. Following a series of discussions between IED and
local residents, a proposal was formulated to set up a "Plan Barrio
Adentro" using small local clinics to provide free healthcare
"inside the neighbourhood" where previously there was none, and to
involve residents in the management of the scheme. Bernal then
issued a call for doctors, but the Venezuelan Medical Federation
put pressure on its members not to apply.[4]
Of the 50 Venezuelan doctors who did apply, 30 left on hearing that
they would need to live in the barrios; the remaining 20 were
specialists and therefore employed in specialist centers and not
required to work in the primary health care centers in the
barrios.[4]
Faced with a lack of willing doctors, Bernal recalled the Cuban
doctors who had provided emergency aid following the 1999 mud
slides, and discussion with the Cuban Embassy in February 2003
ultimately led to a contingent of 58 Cuban doctors starting the
program in April 2003.[6]
In the interim, three Cuban physicians spent a month visiting the
barrios, examining the homes and clinic spaces offered by the
community.[4]
By May 2003 another 100 Cuban doctors arrived, and were sent to
other parts of Libertador and to other municipalities in and around
Caracas.[4]
Besides diagnosis and treatment, including the provision of free
prescription drugs, the doctors carried out a health census of the
barrios, which provided a complete health survey of the Caracas
barrios for the first time.[4]

Despite some obstacles (including a refusal by public hospitals
to accept referrals for diagnosis and treatment, only gradually and
partially overcome during 2003), "Plan Barrio Adentro" became very
popular with its constituents.[4]
By December 2003, "Plan Barrio Adentro"—having seen over 9m patient
consultations and 4m health interventions[4]—was
so popular that it was attracting national attention, and President
Chávez transformed it into a national program, named "Mission
Barrio Adentro" (MBA). It became the first of a series of popular
"missions" bypassing existing public institutions.[6]

Mission
Barrio Adentro

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Barrio Adentro
I

"The key aspect of these centers is that they are located within
the neighborhood and in the marginalized zones of the large
cities,"[5]
although some facilities were located in higher income areas.[6]
"Placement of Barrio Adentro health posts within those
neighborhoods that had been most excluded was undertaken at the
request of the neighborhood health committees and taking into
consideration preexisting health care facilities."[5]

A key part of the national Barrio Adentro scheme, as it was in
the original local plan, is the participation of the local
community. This takes place through health committees, chosen in an
assembly of citizens and typically around 10 people. By 2006, 8951
health committees had been registered (there is one committee for
each primary care post).[5]
(The total was already 6,241 in 2004.[4]
) A total of 41,639 community health assemblies were held in the
first quarter of 2006, with the participation of 1,423,815
people.[4]

The issue of participation goes beyond mere management. As one
academic study put it, "the observed role of positive, egalitarian
clinical interactions between Cuban physicians and Venezuelan
patients and other residents suggests that doctor–patient
interactions model power relations between communities and
institutions and affect local perceptions and participation." It
concluded that developing more positive and egalitarian
physician–patient and professional–community relationships "may be
one of the easiest, most effective ways" the medical profession can
contribute to overcoming health disparities.[6]

Each primary care post covers 250 to 300 families.[5]
By 2003, primary medical care coverage was achieved for 70% of the
Venezuelan population for whom primary care was previously
unavailable, representing over 18m people. By 2007, 3,717 primary
care posts had been built and equipped, and a total of 8,633 posts
were operational (including those still located in community
centers and homes). There were also 4,800 dentists. In 1998
Venezuela had only 1628 staffed primary care posts, and 800
dentists. Between 1998 and 2007 this represents an increase of 530%
and 600% respectively.[5]

In addition to the new infrastructure, there are also new
outreach programmes. For example, in addition to the drug module
for the popular medical dispensaries (which provided free access to
106 essential medicines designed to cover the needs at this level
of care), a family drug module was launched in 2005. This programme
reaches 40 selected municipalities in 17 states, and every three
months delivers drugs and vitamin supplements tailored to the
family's needs. Hundreds of thousands of infants, children, and
pregnant and elderly women have benefited.[4]
Over 150,000 health promoters from local communities were trained
in 2004-6 to spread messages relating to ways of improving
health.[4]

Barrio Adentro
II

After the Barrio Adentro's primary care network went nationwide
in 2004, moves to expand beyond primary care soon followed. What
became known as "Barrio Adentro I" focused on primary health care.
"Barrio Adentro II" focused on secondary care, in three main areas:
Comprehensive Diagnosis Centers (for more advanced diagnosis),
Comprehensive Rehabilitation Centers (for people with disabilities,
another social deficit uncovered by Barrio Adentro I—there were
only 78 public sector centers in 1998), and Advanced Technology
Centers (for more advanced treatment). Plans were made for 600 each
of the first two (each serving a population of approximately 40,000
to 50,000) and 35 of the latter (with at least one in each
state).[5]

As of 2007, Barrio Adentro II involved 417 Comprehensive
Diagnostic Centers (of 600 planned), 576 Comprehensive
Rehabilitation Centers (of 600 planned) and 22 Advanced Technology
Centers (of 35 planned). Key modern technology is split between
CDCs and ATCs (by 2007 CDCs had 13 of the 19 public sector MRI
machines, ATCs 15 of the 26 CT scanners). In 1998, there was only
one MRI machine and five CT scanners in the public sector.[5]

Barrio
Adentro III and IV

Barrio Adentro III provides care for those cases which cannot be
resolved at the two lower levels—major illnesses, palliative and
specialist care. Care is available 24 hours a day.[5]
Barrio Adentro IV is responsible for the most complicated and
specialized medical and surgical needs. These are national and
referral facilities where teaching and research is carried out.[5]
On 16 November 2006 the Chavez government introduced this phase of
the Barrio Adentro project, with a planned 16 hospitals to be built
around the country, especially in poor areas.[11] The
Dr Gilberto Rodríguez Ochoa Latin American Children’s Cardiology
Hospital, inaugurated in 2007,[12] is
the most notable example,[6],
being one of the largest centers of its kind in the world, with 142
hospital beds and 33 intensive care beds.[4]

Achievements

According to the Ministry of Health, only 50 public health
establishments were built in the 1980s and 1990s. Between 2003 and
2007, 4,659 new comprehensive level I and II health care centers
were built and equipped. Services in these centers is provided free
of charge.[5]
In 2004/5 Barrio Adentro provided 150m consultations, four times as
many as the conventional outpatient network; 40% of these were home
visits.[4]

"In surveys conducted by the National Statistics Institute (INE)
in Caracas, 97 percent of the respondents said that they were
satisfied or very satisfied with their general medical
consultations, and 98 percent said they had little or no difficulty
gaining access to health care, while 88.5 percent said that they
had had some or considerable difficulty gaining access to health
care prior to Barrio Adentro."[4]

Between 1998 and 2007, extreme poverty was reduced from 20.6% to
9.41%, while the infant mortality rate fell from 21.3/1000
registered births to 13/1000.[5]

According to one academic study, the successes of the Barrio
Adentro program in 2003 and 2004 may have "crucially inﬂuenced"
Chavez’s 59% to 41% victory in the Venezuelan recall
referendum, 2004.[6]

Criticism

The Venezuelan Medical Federation, the largest association of medical doctors in Venezuela, has lobbied
vigorously against the use of Cuban doctors in Mission Barrio
Adentro, and was in a legal dispute with the Chávez
administration over the legitimacy of the Cuban doctors' licensure
and practice. In 2003 they obtained a court order preventing Cuban
doctors from practicing in Venezuela, on the basis that they were
not properly licenced according to the Venezuelan system; a
compromise was reached enabling them to continue working in Barrio
Adentro.[13][14][15]

Defections

Cuban doctors have continually defected from the Mission since
2004. In August 2006 the United States under George W. Bush
created the Cuban Medical Professional Parole program, specifically
targeting Cuban medical personnel and encouraging them to defect
when they are working in a country outside of Cuba.[16]
As of early 2009, of an estimated 40,000 eligible medical personnel
worldwide (around half in Venezuela), several hundred have applied
under the program.[16]
According to a 2007 paper published in The Lancet medical journal, "growing numbers
of Cuban doctors sent overseas to work are defecting to the USA",
some via Colombia, where they have sought temporary asylum.[17]
In February 2007, at least 38 doctors were requesting asylum in the
US embassy in Bogotá after asylum was denied by the Colombian
government.[18] Cuban
doctors working abroad are reported to be monitored by "minders"
and subject to curfew.[17]

Two defected Cuban doctors working in Venezuela have claimed
that they were told their job was to keep Chavez in power,[19]
by asking patients to vote for Chávez in the 2004 recall
referendum.[19]
Opposition supporters in Venezuela have called Cuban doctors
"Fidel's ambassadors" and refused to go to their clinics.[19]

Abandonment

In July 2007, Douglas León Natera, chairman of The Venezuelan
Medical Federation, reported that up to 70% of the modules of
Barrio Adentro have been either abandoned or were left unfinished
[20]. The
claim that some modules have been abandoned has been backed by
Venezuelan TV reports and other Venezuelan news agencies, although
the state of abandonment and/or unfinished modules has not been
independently verified by any other institution. Cuban health
professionals in Venezuela in 2007 numbered around 39,000, the
highest since the beginning of Barrio Adentro.

In some cases elected opposition officials have tried to impede
or close existing Missions. In 2006 Chávez accused the governor of
Zulia state of impeding Barrio Adentro there.[21]
In Miranda state in February 2009 the governor was reported to have
tried to evict a 25-person Barrio Adentro mission to make room for
office space.[22][23]

As the work of the first primary health care Barrio Adentro
proceeded, censuses began to reveal "the depth of the social
deficits accumulated in these communities."[5]
The response was to expand into a number of new areas, creating new
missions. Thus under Misión Alimentación, efforts are made to
ensure that the vulnerable (children, elderly, etc) receive at
least two meals a day. Misión Robinson was
created to address illiteracy, which in turn led to Misión Milagro
to deal with the revealed deficit of opthalmological care for eye
disease.